Washington State Institute for Public Policy
Cognitive behavioral therapy (CBT) for adult anxiety
Adult Mental Health: Anxiety
Benefit-cost estimates updated December 2016.  Literature review updated September 2016.
Cognitive-behavioral therapies (CBT) include various components, such as cognitive restructuring, behavioral activation, emotion regulation, exposure, communication skills, and problem-solving. Most commonly, treatments in this review provided 10 to 20 therapeutic hours per client in an individual or group modality. Most studies in this analysis focused on a single anxiety disorder (generalized anxiety, obsessive-compulsive, panic, social phobia) with aspects of the treatment tailored to the specific disorder. This review excludes studies of CBT for post-traumatic stress disorder.
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2015). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $10,081 Benefits minus costs $31,340
Participants $21,003 Benefit to cost ratio $56.22
Others $789 Chance the program will produce
Indirect $35 benefits greater than the costs 100 %
Total benefits $31,908
Net program cost ($568)
Benefits minus cost $31,340
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Labor market earnings associated with anxiety disorder $9,444 $20,795 $0 $0 $30,239
Health care associated with anxiety disorder $637 $207 $789 $319 $1,953
Adjustment for deadweight cost of program $0 $0 $0 ($284) ($284)
Totals $10,081 $21,003 $789 $35 $31,908
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $1,458 2015 Present value of net program costs (in 2015 dollars) ($568)
Comparison costs $814 2008 Cost range (+ or -) 10 %
This therapy typically takes place over 10 to 20 weekly sessions. Per-participant costs are based on therapist time as reported in the studies, multiplied by DSHS reimbursement rates reported in Mercer (2014) Behavioral Health Data Book for the State of Washington For Rates Effective January 1, 2015.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Primary or secondary participant No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Anxiety disorder 32 727 -0.525 0.064 37 -0.273 0.078 39 -0.968 0.001
Major depressive disorder 19 384 -0.400 0.080 37 -0.208 0.098 39 -0.784 0.001
Citations Used in the Meta-Analysis

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Barlow, D.H., Gorman, J.M., Shear, M.K., & Woods, S.W. (2000) Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA, 283(19), 2529-2536.

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Beck, A.T., Sokol, L., Clark, D.A., Berchick, R., & Wright, F. (1992). A crossover study of focused cognitive therapy for panic disorder. American Journal of Psychiatry, 149(6), 778-783.

Borkovec, T.D., & Costello, E. (1993). Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 61(4), 611-619.

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Borkovec, T.D., Mathews, A.M., Chambers, A., Ebrahimi, S., Lytle, R., & Nelson, R. (1987). The effects of relaxation training with cognitive or nondirective therapy and the role of relaxation-induced anxiety in the treatment of generalized anxiety. Journal of Consulting and Clinical Psychology, 55(6), 883-888.

Clark, D.M., Salkovskis, P.M., Hackmann, A., Wells, A., Ludgate, J., & Gelder, M. (1999). Brief cognitive therapy for panic disorder: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 67(4) 583-9.

Clark, D.M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., Flower, T., Davenport, C. & Louis, B. (2003). Cognitive therapy versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. Journal of Consulting and Clinical Psychology, 71(6) 1058-67.

Clark, D.M., Ehlers, A., Hackmann, A., McManus, F., Fennell, M., Grey, N., Waddington, L., & Wild, J. (2006). Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(3), 568-78.

Clark, D.M., Salkovskis, P.M., Hackman, A., Middleton, H., Pavlos, A., & Gelder, M. (1994). A comparison of cognitive therapy, applied relaxation, and imipramine in the treatment of panic disorder. British Journal of Psychiatry, 164, 759-169.

Cordioli, A.V., Heldt, E., Braga, B.D. Margis, R., Basso de Sousa, M., Tonello, J. F., Manfro G.G., & Kapczinski, F. (2003). Cognitive-behavioral group therapy in obsessive-compulsive disorder: A randomized clinical trial. Psychotherapy and Psychosomatics, 72(4), 211-216.

Dugas, M.J., Ladouceur, R., Leger, E., Freeston, M.H., Langolis, F., Provencher, M.D., & Boisvert, J.M. (2003). Group cogitive-behavioral therapy for generalized anxiety disorder: Treatment outcome and long-term follow-up. Journal of Consulting and Clinical Psychology, 71(4), 821-825.

Dugas, M.J., Brillon, P., Savard, P., Turcotte, J., Gaudet, A., Ladouceur, R., Leblanc, R., ... Gervais, N.J. (2010). A randomized clinical trial of cognitive-behavioral therapy and applied relaxation for adults with generalized anxiety disorder. Behavior Therapy, 41(1), 46-58.

Foa, E.B., Liebowitz, M.R., Kozak, M.J., Davies, S., Campeas, R., Franklin, M.E., . . . Tu, X. (2005). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. The American Journal of Psychiatry, 162(1), 151-161.

Heimberg, R.G., Liebowitz, M.R., Hope, D.A., Schneier, F.R., Holt, C.S., Welkowitz, L.A., . . . Klein, D.F. (1998). Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome. Archives of General Psychiatry, 55(12), 1133-41.

Kenardy, J.A., Dow, M.G., Johnston, D.W., Newman, M.G., Thomson, A., & Taylor, C.B. (2003). A comparison of delivery methods of cognitive-behavioral therapy for panic disorder: an international multicenter trial. Journal of Consulting and Clinical Psychology, 71(6), 1068-75.

Klosko, J.S., Barklow, D.H., Tassinari, R., Cerny, J.A. (1990). A comparison of Alprazolam and behavior therapy in treatment of panic disorder. Journal of Consulting and Clinical Psychology, 8(1), 77-84

Koszycki, D., Benger, M., Shlik, J., & Bradwejn, J. (2007). Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behaviour Research and Therapy, 45(10), 2518-2526.

Ladouceur, R., Dugas, M. J., Freeston, M. H., Leger, E., Gagnon, F., & Thibodeau, N. (2000). Efficacy of a cognitive-behavioral treatment for generalized anxiety disorder: Evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology, 68(6), 957-964.

Lidren, D.M., Watkins, P.L., Gould, R.A., Clum, G.A., Asterino, M., & Tulloch, H.L. (1994). A comparison of bibliotherapy and group therapy in the treatment of panic disorder. Journal of Consulting and Clinical Psychology, 62(4), 865-869.

Lindsay, W.R., Gamsu, C.V., McLaughlin, E., Hood, E.M., & Espie, C.A. (1987). A controlled trial of treatments for generalized anxiety. British Journal of Clinical Psychology, 26(Pt 1), 3-15.

Lindsay, M., Crino, R., & Andrews, G. (1997). Controlled trial of exposure and response prevention in obsessive-compulsive disorder. The British Journal of Psychiatry : the Journal of Mental Science, 171,135-9.

McLean, P.D., Whittal, M.L., Thordarson, D.S., Taylor, S., Söchting, I., Koch, W.J., Paterson, R., ... Anderson, K.W. (2001). Cognitive versus behavior therapy in the group treatment of obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 69(2), 205-14.

Mörtberg, E., Karlsson, A., Fyring, C., & Sundin, O. (2006). Intensive cognitive-behavioral group treatment (CBGT) of social phobia: A randomized controlled study. Journal of Anxiety Disorders, 20(5), 646-660.

Sharp, D.M., Power, K.G, Simpson, R.J., Swanson, V., Moodie, E., Anstee, J.A., & Ashford, J.J. (1996). Fluvoxamin, placebo, and cognitive behaviour therapy used alone and in combination in the treatment of panic disorder and agoraphobia. Journal of Anxiety Disorders, 10(4), 219-242.

Stangier, U., Schramm, E., Heidenreich, T., Berger, M., & Clark, D.M. (2011). Cognitive therapy vs interpersonal psychotherapy in social anxiety disorder: a randomized controlled trial. Archives of General Psychiatry, 68(7), 692-700.

Telch, M.J., Lucas, J.A., Schmidt, N.B., Hanna, H.H., LaNae, J.T., & Lucas, R.A. (1993). Group cognitive-behavioral treatment of panic disorder. Behaviour Research and Therapy, 31(3), 279-287.

White, J., Keenan, M., & Brooks, N. (1992). Stress control: A controlled comparative investigation of large group therapy for generalized anxiety disorder. Behavioural Psychotherapy, 20(2), 97-114.

White, J., Brooks, N., & Keenan, M. (1995). Stress control: A controlled comparative investigation of large group therapy for generalized anxiety disorder: Process of change. Clinical Psychology & Psychotherapy, 2(2), 86-97.

Williams, S.L., & Falbo, J. (1996). Cognitive and performance-based treatments for panic attacks in people with varying degrees of agoraphobic disability. Behaviour Research and Therapy, 34(3), 253-64.

For more information on the methods
used please see our Technical Documentation.
360.664.9800
institute@wsipp.wa.gov